Early vs. Late Vitrectomy for Retained Lens Fragments After Phaco

I have recently read several articles on on the issue of retained lens fragments after phaco, and to me, it seems like a no-brainer- better to tell the patient about the complication and have the patient seen by the retinologist the next day. I think the only reason cataract surgeons delay the referral is that they are in a state of denial. They just don’t want to face the ordeal of explaining the situation to the patient, seeing their discouraged faces, and thinking about all the post-op visits and hand-holding the patient will need. We also look at the whole scenario as an affront to our skills, an insult. We take the whole thing very personally and wonder why we, and no one else, gets these complications. It’s a little bit irrational. Let’s gather the strength to do what’s in the best interest of our patients and will help us in the legal arena- refer the patient immediately.

As a retina specialist, retained lens fragments or dropped nuclei are a personal insult to the cataract surgeon. I usually field an urgent call, a day or two after cataract surgery, explaining how the difficult anatomy (e.g. small pupil, narrow lid fissure, etc.) or how the patient moved (e.g. usually a sudden cough) during surgery to cause this catastrophe! Do not take this personally, it happens to every cataract surgeon.

This need not be a catastrophe for you or your patient. By acknowledging the complication or the inability to achieve the goal immediately, you maintain your patients trust and confidence in you. Trying to deny the complication only makes matters worse. Any confidence in you becomes eroded after days of poor vision, pain and confusion.

When (not if) a lens does drop, I suggest the following;

1. Do not go after the lens yourself. (If you create a tear, a retinal detachment in this scenario is even worse. I personally feel an anterior vitrectomy is unwarranted.)

2. Place a PCIOL if you can, an ACIOL is fine, too. (This does not complicate surgery for the retinal surgeon. It usually prevents a separate procedure for placing an IOL later on and helps you fulfill more of your original treatment plan.)

3. Do not consider an anterior vitrectomy unless it prohibits placing an IOL. (Having said that, I would recommend scrapping the idea of an IOL altogether if you think you need an anterior vitrectomy.)

4. Finish the case with a miotic.

5. Close the wound with sutures, even in sutureless cases! (Because a pars plana approach for vitrectomy/lensectomy is anticipated, suture closing will stabilize the corneal wound and prevent it from opening during the vitrectomy. Hypotony and iris prolapse can be avoided.)

6. Place on Diamox. (Keeps the pressure low and the cornea clear.)

7. Tell the patient/family immediately that you were unable to remove the cataract completely and you may be considering referral to a colleague to help in this situation. (Continue to be their doctor by providing them with the best care and guidance you can deliver. Your patients will return and thank you!)